Neurology for the masses

Neurologists, I’m pleased to report, seem to be coming down to earth. Stereotypes go deep in medicine, and the neurologist is one of the great archetypes: a brilliant, forgetful man with a bulging cranium, a loud bow tie, who reads Cicero in Latin for pleasure, hums Haydn sonatas, talks with ease about bits of the brain you’d forgotten existed, adores diagnosis and rare syndromes, and—most importantly—never bothers about treatment. A J Larner and S F Farmer explode at least some of these myths in their review of recent advances in neurology by plunging straight into treatment of common conditions (p 362).

Neurological conditions account for 10-20% of acute hospital admissions, and 10% of the adult population consults a general practitioner with a neurological problem each year. In Britain only 10% of these are referred to neurologists, so most patients are managed by doctors without specialist training.

The treatment of stroke is becoming increasingly complex. Aspirin should be started as soon as possible in patients with acute ischaemic stroke, but there is no way clinically to differentiate ischaemic from haemorrhagic stroke. All patients thus need brain imaging, placing a huge burden on hospitals. More difficult still, there is mounting evidence that some patients will benefit from thrombolytic therapy given within three hours. They need imaging as well as rapid admission to hospital. Magnetic resonance imaging is also needed in the 20% to 30% of newly diagnosed patients with epilepsy in whom seizures are refractory. Three quarters have abnormalities, some of which are amenable to surgery.

Larner and Farmer then work their way through multiple sclerosis, Parkinson’s disease, dementia, and migraine, devoting only two paragraphs to “rare disorders.” The conclusion is that recently untreatable diseases are becoming treatable—but usually at high cost. So the once other worldly neurologist is now on the front line of healthcare rationing.

Two fillers provide a counterpoint to the data driven wisdom of the neurologists. Olive McKendrick describes a mother talking to her 6 year old son with cystic fibrosis about his fear of dying. Instinctively the mother recognised that truth is not the opposite of a lie. Rather, truth is a ladder. Simon Power tells not of a child but of an old sailor, his uncle, and admires him for refusing to listen to doctors. He drank heavily all his life, making an informed (and who is to say wrong?) choice.

Finally, we have a new Soundings columnist, Ricardo Silva, a psychiatrist from Sao Paulo. He reads as a grasshopper eats—“anything, anywhere, anytime”—and begins his column on the pilgrims’ trail to Santiago de Compostela.